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Risk Adjustment Program Compensation: Fewer Targets, Greater Opportunities
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 10, 2026
Summary
Effective January 1, 2027, Highmark is simplifying its Risk Adjustment Program by removing four high-prevalence Part D conditions (Thyroid Disorders, Anxiety/Psychiatric Disorders, Hypertension, Coronary Artery Disease) from targeting and restructuring bonus tiers for gap assessments across Medicare Advantage, D-SNP, ACA, and Medicaid plans. These changes reduce targeted conditions by approximately 50% and introduce new tiered payment thresholds to reward higher performance levels.
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What to do
by Jan 1, 2027 · 3 steps
01Billing and provider relations teams should review the updated risk adjustment compensation structure for all applicable plans (Medicare Advantage, D-SNP, ACA, and Medicaid).
02Verify in the practice's risk adjustment tracking systems that the four removed Part D conditions (RxHCC 44, 133, 187, 188) are no longer targeted for gap assessment and confirm the new bonus tier thresholds are reflected in gap closure reporting and payment reconciliation processes.
03Contact the primary Highmark risk adjustment contact to confirm current program participation status and obtain updated targeting lists from the Provider Resource Center (PRC via Availity Essentials) to ensure accurate gap prioritization starting in 2027.
Original notice
Risk Adjustment Program Compensation: Fewer Targets, Greater Opportunities
providers.highmark.com · Always check the source before changing claims.